GEMC: Case Presentation- Pericarditis: Resident Training

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Information about GEMC: Case Presentation- Pericarditis: Resident Training

Published on March 10, 2014

Author: openmichigan



This is a lecture by Kwaku Nyame from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License:

Project: Ghana Emergency Medicine Collaborative Document Title: Case Presentation- Pericarditis Author(s): Kwaku Nyame License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1

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Case Presentation - Pericarditis Kwaku Nyame 3

History } 38 year old female, presented to A&E with a compliant of } Chest pain – 1 week } Worsening Difficulty in breathing – 1 week } What other things will you want to find out and why 4

History } Told had a heart condition 3yrs ago, given medication but now not on any medication } Currently not on any medication 5

Physical Exams }  Warm to touch, temp 38.1 o c, obesed }  HR – 112bpm, Regular, }  BP – 100/68 mmHg }  AB – 5th LICSMCL }  JVP – not raised, neck veins, not distended }  There is a murmur 6

Physical Exam ctd }  RR 38cpm, FAN+, ICR+ }  SPO2 off oxygen – 94% }  Chest is clear }  Abd, NAD }  CNS - Intact 7

DDx }  AMI }  PE }  Aortic dissection }  Pneumonia }  Pneumothrax }  Acute pericarditis }  costochondritis 8

Investigations }  Cardiac Enzymes – }  ECG – }  CBC }  RFT }  Bedside USG }  Echocardiography }  CXR 9

Acute Pericarditis }  Acute pericarditis is more common in young adults (typically between 20 to 50 years old) and in men. }   The true incidence and prevalence unknown }  However, it may account for up to 5% of presentations to emergency departments for chest pain and up to 0.1% of hospital admissions. 10

Acute Pericarditis - Etiology }  Idiopathic }  Viral Infections }  Pyogenic Infections }  Tuberculosis Infections }  Systemic autoimmune dx – RH, Systemic lupus, reiters syn }  Metabolic - uremia, severe hypothyroidism }  Post MI – Dresslers’ syndrome }  Procedures – radiotherapy, percutanuos cardiac interventions }  Drugs – Hydralazine, phenytoin, procainamide 11

Classification }  Clinical classification }  Pericarditis can be classified by duration of inflammation as well as by etiology. }  A.Acute pericarditis (<6-week duration) }  Fibrinous }  Effusive (serous or serosanguineous) }  B. Subacute pericarditis (6-week to 6-month duration) }  Effusive-constrictive (characterized by the combination of tense effusion in the pericardial space and constriction by the thickened pericardium) }  Constrictive 12

Classification }  C. Chronic pericarditis (>6-month duration) }  Constrictive }  Effusive }  Adhesive (nonconstrictive) }  D. Recurrent pericarditis }  Intermittent type (symptom-free intervals without therapy) }  Incessant type (relapse occurs with discontinuation of anti-inflammatory therapy). 13

Signs and Symptoms }  Chest Pain - SOCRATES }  Myalgia }  Fever }  Hiccups }  Pericardial Rub – in 85% of patients(100% specific) }  Signs of right heart failure with normal ejection fraction }  Presence or absence of effusion 14

Test to order }  ECG -upward concave ST-segment elevation globally with PR depressions }  serum troponin- mildly elevated }  ESR - may be elevated }  C-reactive protein - may be elevated }  BUN elevated >60 mg/dL in renal failure }  CBC - elevated white blood cells 15

Test to order, ECG findings }  Serial ECG may be diagnostic }  Stage I }  Stage II }  Stage III }  Stage IV }  ST amplitude / T amplitude > 0.25 high index of suspecion for pericarditis ( 85% sensitivity and 80% specificity) 16

ECG Source Undetermined 17

Test to order }  Chest x-ray - normal or water-bottle-shaped enlarged cardiac silhouette }  Echocardiography - may show a pericardial effusion; absence of LV wall motion abnormalities, }  Chest CT pericardial effusion or constrictive pericarditis }  Pericardiocentesis/biopsy - acid-fast bacilli, positive culture of Mycobacterium tuberculosis 18

Treatment }  ABC IV O2, Monitor }  Directed at any identified underlying disorder }  Supportive management directed at relief of symptoms. }  Hospitalization is generally recommended to determine etiology, observe for complications such as cardiac tamponade, and gauge response to therapy. 19

Treatment }  NSAIDs, Ibuprofen preferred, Aspirin preferred for post MI pericarditis for 4 weeks }  PPIs }  Limit exercise till chest pain resolves }  If after 2 wks, pain persist, add colchicine for 3 month }  If pain still persist, add systemic steroids }  Recurrent non-purulent disease, consider azathioprine 20

Complications- Pericadial Effusion Empirical Estimates 0.5- 0.8 cm 200mls 0.9 – 1.4cm 300 – 500ml 1.5 – 1.8cm 600 – 1000mls If pyogenic cause of effusion suspected, drain the effusion and treat underlying infection. Ie antibiotics or anti-TB 21

Complications – Constrictive Pericarditis }  Similar to Right sided heart failure, restrictive cardiomyopathy }  Signs – elevated JVP with rapid y deecnt, kussmaul sign, pericardial knock, ascitis, dependent edema and hepatomegaly }  ECG – low voltage, inverted t wave, no classic finding }  Radiograph - pericardial thickening + calcicication }  Rx - Pericardioectomy 22

Complications- Cardiac Tamponade }  Dyspnea, profound exertional intolerance with symptoms of underlying cause }  Exam – Tachycardia, low systolic BP with narrow pulse pressure, Distended neck viens with absent y decent, Pulsus paradoxus , distant or soft heart sounds, right upper quadrant abd pain }  CXR – may be normal, an epicardial fat-pad sign (15%) }  ECG – low voltages, electric alternans }  ECHO – diagnostic tool of choice }  Rx- Iv fluids, Pericardiocentesis with insertion of pigtail catheter , Rx of underlying cause 23

Ref }  Emergency Medicine,A comprehensive Study Guide }  Principles of Medicine in Africa } 24

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